Direct peritoneal resuscitation from hemorrhagic shock: effect of time delay in therapy initiation

Abstract

Background: After conventional resuscitation from hemorrhagic shock, splanchnic microvessels progressively constrict, leading to impairment of blood flow. This occurs despite restoration and maintenance of central hemodynamics. The authors' recent studies have demonstrated that topical and continuous ex vivo exposure of the gut microvasculature to a glucose-based clinical peritoneal dialysis solution (Delflex), as a technique of direct peritoneal resuscitation (DPR), can prevent these postresuscitation events when initiated simultaneously with conventional resuscitation. This study aimed to determine whether DPR applied after conventional resuscitation reverses the established postresuscitation intestinal vasoconstriction and hypoperfusion.

Methods: Male Sprague-Dawley rats were bled to 50% of baseline mean arterial pressure and resuscitated intravenously over 30 minutes with the shed blood returned plus two times the shed blood volume of saline. Initiation of ex vivo, topical DPR was delayed to 2 hours (group 1, n = 8), or to 4 hours (group 2, n = 8), respectively, after conventional resuscitation. Intravital microscopy and Doppler velocimetry were used to measure terminal ileal microvascular diameters of inflow A1 and premucosal A3 (proximal pA3, distal dA3) arterioles and blood flow in the A1 arteriole, respectively. Maximum arteriolar dilation capacity was obtained from the topical application, in the tissue bath, of the endothelium-independent nitric oxide-donor sodium nitroprusside (10M).

Results: Hemorrhagic shock caused a selective vasoconstriction of A1 (-24.1% +/- 2.15%) arterioles from baseline, which was not seen in A3 vessels. This caused A1 blood flow to drop by -68.6% of the prehemorrhage value. Conventional resuscitation restored and maintained hemodynamics in all the animals without additional fluid therapy. In contrast, there was a generalized and progressive postresuscitation vasoconstriction of A1 (-21.7%), pA3 (-18.5%), and dA3 (-18.7%) vessels. The average postresuscitation A1 blood flow was -49.5% of the prehemorrhage value, indicating a persistent postresuscitation hypoperfusion. Direct peritoneal resuscitation reversed the postresuscitation vasoconstriction by 40.9% and enhanced A1 blood flow by 112.9% of the respective postresuscitation values.

Conclusions: Delayed DPR reverses the gut postresuscitation vasoconstriction and hypoperfusion regardless of the initiation time. This occurs without adverse effects on hemodynamics. Direct peritoneal resuscitation-mediated enhancement of tissue perfusion results from the local effects from the vasoactive components of the Delflex solution, which are hyperosmolality, lactate buffer anion, and, to a lesser extent, low pH. The molecular mechanism of this vasodilation effect needs further investigation.

Figures

Fig. 1

Time line of the experimental protocol. The arrow shows the timing for initiation of direct peritoneal resuscitation (DPR). MAP, mean arterial pressure; CR, conventional resuscitation

Fig. 2

Effects of a 2-hour delay in the initiation of direct peritoneal resuscitation (DPR) on mean arterial pressure (MAP) (upper panel), microvascular diameter (middle panel), and intestinal A1 blood flow (lower panel). BL, baseline; HS, hemorrhagic shock; post-CR, postconventional resuscitation; A1, intestinal inflow arteriole; pA3, proximal A3 premucosal arteriole; dA3, distal A3 premucosal arteriole. * p < 0.001 versus BL by two-way analysis of variance (ANOVA) and Bonferroni posttest. § p < 0.05 versus BL by two-way ANOVA and Bonferroni posttest. † p < 0.01 versus post-conventional resuscitation by two-way ANOVA and Bonerroni posttest.

Fig. 3

Effects of a 4-hour delay in initiation of direct peritoneal resuscitation (DPR) on mean arterial pressure (MAP) (upper panel), microvascular diameter (middle panel), and intestinal A1 blood flow (lower panel). BL, baseline; HS, hemorrhagic shock; post-CR, postconventional resuscitation; A1, intestinal inflow arteriole; pA3, proximal A3 premucosal arteriole; dA3, distal A3 premucosal arteriole. *p < 0.001 versus BL by two-way analysis of variance (ANOVA) and Bonferroni posttest. §p < 0.05 versus BL by two-way ANOVA and Bonferroni posttest. † p < 0.01 versus post-conventional resuscitation by two-way ANOVA and Bonerroni posttest.

Fig. 4

Magnitude of direct peritoneal resuscitation (DPR)-mediated dilation in intestinal microvasculature after 2-hour and 4-hours delays in DPR therapy initiation (upper and lower panels, respectively). A1, intestinal inflow arteriole; pA3, proximal A3 premucosal arteriole; dA3, distal A3 premucosal arteriole.